MEDICARE: TARA L BRENISER LMT, MMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT-12663	AZ
2	225700000X	Massage Therapist	MT21806621	IN

General Provider Information

NPI Number	:	1669885216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA L BRENISER LMT, MMP

Provider Business Mailing Address
First Line	:	801 WAYNE ST STE 6
Second Line	:
City	:	MIDDLEBURY
State	:	IN
Zip	:	46540-9074
Country	:	US
Telephone Number	:	480-221-7514
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 WAYNE ST STE 6
Second Line	:
City	:	MIDDLEBURY
State	:	IN
Zip	:	46540-9074
Country	:	US
Telephone Number	:	480-221-7514
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2014
Last Update Date	:	02/06/2025

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